11/16/2015

History of Wound Care &

Pressure Ulcers:
Past, Present & Future
Jeffrey M. Levine MD, AGSF, CWSP

November 19, 2015

The National Pressure Ulcer

Advisory Panel (NPUAP)
serves as the authoritative
voice for improved patient
outcomes in pressure ulcer
prevention and treatment
through public policy, education
and research.

npuap.org
©2015 National Pressure Ulcer Advisory Panel | www.npuap.org

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NPUAP – in collaboration with the

European Pressure Ulcer Advisory
Panel (EPUAP) and the Pan Pacific
Pressure Injury Alliance (PPPIA) –
has worked to develop a NEW
pressure ulcer prevention and
treatment Clinical Practice
Guideline and a companion Quick
Reference Guide.
Purchase your copy today at
www.npuap.org
npuap.org
©2015 National Pressure Ulcer
Advisory Panel | www.npuap.org

Released in November 2012, the 254-page,

24 chapter monograph, Pressure Ulcers:
Prevalence, Incidence and Implications for the
Future was authored by 27 experts from NPUAP
and invited authorities and edited by NPUAP
Alumna Dr. Barbara Pieper.
The monograph focuses on pressure ulcer rates
from all clinical settings and populations; rates in
special populations; a review of pressure ulcer
prevention programs; and a discussion of the state
of pressure ulcers in America over the last decade.
Purchase the monograph today at www.npuap.org
 E-version $49
 Individual Chapters $19

npuap.org
©2015 National Pressure Ulcer
Advisory Panel | www.npuap.org

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npuap.org

25 – 29 September

www.wuwhs2016.com

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Medline Industries

Molnlycke Health Care

Sage Products

Smith & Nephew

The NPUAP webinar commercial supporters

did not have any input regarding the content
of this presentation.

Jeffrey Levine, MD

Dr. Levine, has listed no financial

interest/arrangement that would be considered
a conflict of interest.

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 Joyce Black, PhD, RN, CWCN, FAAN

 Jeffrey Levine, MD
 Mary Litchford, PhD, RD, LDN
 Sally O’Neill, PhD
 Mary Sieggreen, MSN, CNS, NP, CVN

The planning committee members have listed

no financial interest/arrangements that would
be considered a conflict of interest.

 Janet Cuddigan
 Joyce Black
 Elizabeth Ayello
 Art Stone
 Jen Bank
 New York Academy of Medicine
 Majno, G. The Healing Hand.
Harvard University Press 1991.

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 Review the history of pressure ulcers and wound

care from ancient times to the present

 Review the origin of contemporary controversies

and challenges

 Highlight major issues facing today’s

practitioners caring for pressure ulcers

 Explain what the experts say about the future of

pressure ulcers and wound care

Edwin Smith Papyrus 2600 BC

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Imhotep
Egyptian God of Medicine

 Cooling agents to draw out inflammation

 Drying agents
 Raw meat bound to the wound
 Linen bandages
 Honey
 Incantations to the gods
Levine. JAMDA 1: 224-227; 2000

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Foreshadowing of palliative care principles:

 Lesion that can be treated and will

most likely be cured

 Lesion that can be treated but may

not be cured

 Lesion with hopeless prognosis,

treatment not offered
Levine. JAMDA 1: 224-227; 2000

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Hippocrates of Kos
460 BC

“The herb which has got the

name of lagopyrus, fills up hollow
and clean ulcers…”

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Achilles
healing the
wound of
Telephos

Philoctetes
on the Island of
Lemnos

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Babylonian
Talmud

Centuries of
oral tradition
written in the
5th Century

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“An open wound … What is the remedy? — For stopping the bleeding,
cress with vinegar; for bringing on [flesh], scraped root of cynodon and the
paring of the bramble, or worms from a dunghill.”

“wet for dry, dry for wet”

Avoda Zara 28b
“One who inflicts a wound on his fellow can be liable on account
of him for five things - five aspects of the injury:

* for actual damage;

* for pain;
* for healing;
* for loss of employments;
* and for humiliation.”
“Where the wound was healed but reopened, healed again but
reopened, he would still be under obligation to heal him…”
Baba Kamma 83a

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• Uroscopy
• Astrology
• Bloodletting
• Plague
• Dissection
• Wound
Treatment

“For running and painful wounds

wherever they are, take an oil fish
and boil it. Take the fat from it and
keep it in a clean container. Boil a
hen and do not add any fat to it.
Separate the fat from the hen,
collect it, and add it to juice of
sage, rue, worm-wood, horhound,
and wild mint. Put that all together
and smear the [wound] with it.
They will heal.”

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“The Wound Man”

(Der Verwundete Mann)

Germany, 1528

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Ambrose Paré
1510-1590

 Soft pillows
 Prayer
 Nutrition
 Abscess drainage
 Pain management
 Aromas
 Pleasant sounds
 Various plasters and unguents

Levine. Decubitus 5: 23-26, 1992

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“…we should put him in another bed,

very soft, and give him clean shirt
and sheets….”

“…we should make him a little pillow

of down to keep his buttock in the air,
without his being supported on it.”

Ambrose Paré
Levine. Decubitus 5: 23-26, 1992

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Jean-Martin Charcot
1825-1893

 Decubitus acutus
 Decubitus chronicus
 Decubitus ominosus

Levine. JAGS 53: 1248; 2005

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Decubitus wounds were unavoidable

consequences of damage to the CNS

Levine. JAGS 53: 1248; 2005

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“On guinea pigs… I have

found that no ulceration
appeared when I took care
to prevent … a continued
state of compression, and
washing them to remove
urine and feces.”

Charles-Edouard
Brown-Sequard
1817-1894

Levine. JAGS 53: 1248; 2005

Florence Nightingale
(1820-1910)

“…if [the patient] has a

bed-sore, it is generally
the fault not of the
disease, but of the
nursing. .”

Notes on Nursing
1859

38

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Wound Care & War in the 19th Century

Picture Credit: Sons of Union Veterans of the Civil War

Picture credit: Burns Archive

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Wound Care & WWI

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Alexis Carrel Henry Drysdale Dakin

1873-1944 1880-1952

Carrel-Dakins Solution

Levine JM. Adv Skin Wound Care 26: 410; 2013.

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Administration of
Carrel-Dakins Solution

Levine JM. Adv Skin Wound Care 26: 410; 2013.

Carrel-Dakins Solution
Dakins Solution

Levine JM. Adv Skin Wound Care 26: 410; 2013.

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Wound Care
& WWII

 Evacuation logistics
 Plasma transfusions
 Antibiotics
 Body casts for unstable fractures

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Pressure Sores Classification and Management

Clinical Orthopaedics and Related Research, V 112 Oct 1975

Pressure Sores Classification and Management

Clinical Orthopaedics and Related Research, V 112 Oct 1975

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4 Stage System for PrU

Classification

Shea 1975 + IAET (now WOCN

Society) 1988

First NPUAP Consensus

Conference 1989

20th Century Pioneers

Michael Kosiak MD
1942-2012

Kosiak M. Etiology of Decubitus Ulcers. Arch Phys

Med Rehabil 42: 19-29, 1961

Experimental studies on the relationship of pressure

to tissue damage

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20th Century Pioneers

Thomas Stewart PhD

Founding member of NPUAP: 1987

20th Century Pioneers

Roberta L. Abruzzese EdD, RN, FAAN

1933-2005

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20th Century Pioneers

Barbara Braden PhD, RN, FAAN

§483.25-C Pressure Sores

Based on the comprehensive Assessment of a resident, the facility must

ensure that—

(1) A resident who enters the facility without pressure sores does not
develop pressure sores unless the individual’s clinical condition
demonstrates that they were unavoidable; and

(2) A resident having pressure sores receives necessary treatment and

services to promote healing, prevent infection and prevent new sores
from developing.

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 Association of PrU with staffing levels &

implementation of prevention measures

 Decubitus 2(2) May 1989. p.44-45

observations challenging the common
notion that PrU reflect quality, subsequently
known at the KTU

AHCPR Guidelines

1992 1995

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By the close of the 20th Century

 Universally recognized Quality Indicator: CMS, JCAHO, NQF,
etc.
 Very limited push-back to the PU-Quality link other than KTU
 Multi-billion $$ industry
 Growing risk-management/medical-legal issue
 Incorporated into regulations & government policy
 Healthcare environment pushing for evidence based CPGs
 Healthcare environment pushing for P4P
 Numerous treatment modalities and little clinical research
 Continued collaboration of experts and the growth of
professional societies
 Recognition of PrU as a “geriatric syndrome.”

The 21st Century

 International collaboration for CPGs
 Link between PrU and P4P in hospitals, i.e. HACs
 Continued proliferation of prevention & wound healing technologies
 Increased sophistication of our knowledge of pressure related injury
 Addition of Unstageable and DTI to the staging system
 Knowledge of Biofilms
 Emergence of regenerative medicine and bioengineered skin
substitutes
 Focus on special populations: Bariatric, Critically Ill, SCI, Pedes, Geri
 Proliferation of wound healing centers
 Emergence of new societies and certifications
 Emergence of concepts of skin failure and unavoidability
 Emergence of palliative strategies
 Development of dedicated EMRs and APPs

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2009 2014

21st Century Cutting Edge Issues

 Skin failure; Skin changes and the dying process
 Unavoidable PrU’s
 Preventive dressings
 DTI pathophysiology, medical device related PrU
 Research on turning frequency
 Moisture related skin damage
 OR and ICU acquired PrU’s
 Palliative care for nonhealing wounds
 Wound bed preparation
 Public policy, reimbursement, coding, improved F-tags in LTC
 Tissue repair and molecular pathogenesis of chronic wounds
 Clinical education, bringing knowledge to the bedside

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The Future…. What do

NPUAP Board Members Say?
 Implementation and validation of new technologies
 Improved device approval methodology by FDA
 Define the relationship between anticoagulation and DTI
 Improved diagnostic tools: biomarkers for DTI and healing
 Early detection and diagnosis of DTI
 Better understanding of tissue tolerance
 Escalation of prevention for very high risk groups
 Modifying quality measures to account for unavoidable PrUs
 Improved evidence based research for healing modalities
 Improved organization of wound care as a multidisciplinary
specialty
 Improved diagnosis of MASD vs Stage 2 PrUs
 Improved understanding of unavoidable PrUs and skin failure

 Prevention in critically ill/ICU settings with early

detection of DTI

 Improved presence of wound care in the

medical school curriculum

 More evidence for palliative care principles

 Unified theory of skin failure

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QUESTIONS??

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To earn the 1.0 continuing education credit from

today’s webinar please visit the link below.

https://blueq.co1.qualtrics.com/SE
/?SID=SV_erhQsFrepFQMIsd

This information will also be emailed out to

participants one hour after the conclusion of the
webinar.

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